NOTICE OF PRIVACY PRACTICES

On April 14, 2003, the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) went into effect. This Rule regulates how patients’ information is used and disclosed. It also clarifies patients’ rights and clinicians’ responsibilities regarding confidential information. This Notice is an explanation of the Privacy Rule. Please review it carefully.

* Treatment is when a clinician provides, coordinates or manages your care: An example of treatment would be when he/she consults with another health insurer to obtain reimbursement or to determine eligibility or coverage.

* Payment is when the clinician obtains reimbursement for your healthcare: Examples of payment are when he/she discloses your PHI to your health insurer to obtain reimbursement or to determine eligibility or coverage.

* Health Care Operations are activities that relate to the performance and operation of Rasi AssociatesTo help clarify, here are some definitions:

• “PHI” refers to information in your record that could identify you. • “Treatment, Payment and Health Care Operations” • “Use” applies only to activities within Rasi Associates. • “Disclosure” applies to activities outside of Rasi Associates, such as releasing information about you to other parties.

II. Uses and Disclosures Requiring Authorization: Your therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations only with your written authorization. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when a clinician is asked for information for purposes outside of treatment, payment and health care operations, he/she will obtain an authorization from you before releasing this information. He/she will also need to obtain an authorization before releasing his/her psychotherapy notes. “Psychotherapy notes” are notes the clinician might have made about conversations during a private, group, joint, or family counseling session, which he/she would have kept separate from the rest of your clinical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization once your therapist has already acted on it; or if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization: A clinician may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If in his/her professional capacity, your therapist has reasonable cause to believe that a minor child is suffering physical, sexual or emotional abuse which causes the child harm or substantial risk of harm, the clinician must report such cases to the Massachusetts Department of Social Services.

• Adult and Domestic Abuse: If the clinician has reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, he/she must immediately report it to the Massachusetts Department of Elder Affairs.

• Health Oversight: The Board of Registration of clinicians has the power, when necessary, to subpoena relevant records should your therapist be the focus of an inquiry.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis, treatment and the records thereof, such information is privileged under state law and your therapist will not release information without written authorization from you or your legally-appointed representative, or a court order.

• Serious Threat to Health or Safety: If you communicate to your therapist an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, your therapist must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. He/she must also do so if he/she knows you have a history of physical violence and he/she believes there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and your therapist has a reasonable basis to believe that you can be committed to a hospital, your therapist must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.

• Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.

IV. Patient’s Rights and Therapist’s Duties

Patient’s Rights:

1. Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI. However, your therapist is not required to agree to a restriction you request.

2. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, requesting that your bill not be sent to your home address.)

3. Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you, for as long as the PHI is maintained in the record. Your therapist may deny your access to PHI under certain circumstances. On your request, your therapist will discuss this process with you.

4. Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request. On your request, he/she will discuss with you the details of the amendment process.

5. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, your therapist will discuss with you the details of the accounting process.

6. Right to a Paper Copy – You have the right to obtain a paper copy of this Notice, even if you have agreed to receive the notice electronically.

Therapist’s Duties:

1. Your therapist is required by law to maintain the privacy of PHI and to provide you with a notice of his/her legal duties and privacy practices with respect to PHI.

2. Rasi Associates reserves the right to change the privacy policies and practices described in this notice. Unless Rasi Associates notifies you of such changes, however, it is required to abide by the terms currently in effect.

3. If these policies and procedures are changed, Rasi Associates will notify you in writing.

V. Complaints: If you are concerned that Rasi Associates or your therapist has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact Victoria B. Paratore, Psy. D. She can be reached at 617.266-2266 Ext. 150. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy: This notice went into effect on April 14, 2003. Rasi Associates reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained. If so, Rasi Associates will provide you with a revised notice by mail.